Outpatient Therapy (OT) Exercises Checklist

Published 09/26/2019

Providers can use this checklist as an audit tool to help assure that they are submitting all required documentation.  

Outpatient Therapy (OT) Exercises Checklist Yes No N/A
Does the certification have a dated signature on the plan of care or some other document that indicates approval of the plan of care? (Refer to Medicare Benefit Manual 100-02 Chapter 15 Section 220.)      
Is the documentation supporting medical necessity legible, relevant and sufficient to justify the services billed?      
Is the documentation in the medical records sufficient to determine that a service was performed on specific dates, and the medical necessity of the service(s) rendered?      
Is the initial evaluation and plan of care, including any other pertinent characteristics of the beneficiary such as type, amount, frequency, and duration of services, documented?      
Is the documentation submitted for the correct beneficiary?      
Is the documentation submitted for the correct dates of service?      
Is there documentation of a history and physical exam pertinent to the patient’s care (including the response or changes in behavior to previously administered skilled services)?      
Are the skilled services provided documented?      
Is there a detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences?      
Is there documentation of the complexity of the service to be performed?      
Is there documentation of progress notes written by the clinician for services related to progress reports furnished on or before every 10th treatment day?      
Is there documentation of any previous therapy administered?      
Is the discharge note or summary documented?      
Is documentation provided showing when an evaluation or re-evaluation is furnished and billed?      
Is the physician’s order for therapy present? (Must be dated and have a legible signature of the of the physician and/or non-physician practitioner.)      
Is the treatment diagnosis and/or medical diagnosis present?      
Is the diagnosis onset date present in the plan of care?      
Is the level of function at the onset of therapy and current level of function, including affected activities of daily living documented?      
Does the plan of care include long/short term goals that are objective and measurable?      
Is there documentation of therapy encounter notes detailing services provided for each date of service billed and treatment modality?      
Does the documentation justify that the individual is under the care of a physician or nonphysician practitioner or require the services of a therapist?      
Is the therapy furnished while the individual is or was under the care of a physician?      

Disclaimer: This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS’s documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.

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